COVID-19 Bivalent Booster Vaccination Coverage and Intent to Receive Booster Vaccination Among Adolescents and Adults — United States, November–December 2022

COVID-19 vaccine booster doses are safe and maintain protection after receipt of a primary vaccination series and reduce the risk for serious COVID-19-related outcomes, including emergency department visits, hospitalization, and death (1,2). CDC recommended an updated (bivalent) booster for adolescents aged 12-17 years and adults aged ≥18 years on September 1, 2022 (3). The bivalent booster is formulated to protect against the Omicron BA.4 and BA.5 subvariants of SARS-CoV-2 as well as the original (ancestral) strain (3). Based on data collected during October 30-December 31, 2022, from the National Immunization Survey-Child COVID Module (NIS-CCM) (4), among all adolescents aged 12-17 years who completed a primary series, 18.5% had received a bivalent booster dose, 52.0% had not yet received a bivalent booster but had parents open to booster vaccination for their child, 15.1% had not received a bivalent booster and had parents who were unsure about getting a booster vaccination for their child, and 14.4% had parents who were reluctant to seek booster vaccination for their child. Based on data collected during October 30-December 31, 2022, from the National Immunization Survey-Adult COVID Module (NIS-ACM) (4), 27.1% of adults who had completed a COVID-19 primary series had received a bivalent booster, 39.4% had not yet received a bivalent booster but were open to receiving booster vaccination, 12.4% had not yet received a bivalent booster and were unsure about getting a booster vaccination, and 21.1% were reluctant to receive a booster. Adolescents and adults in rural areas had a much lower primary series completion rate and up-to-date vaccination coverage. Bivalent booster coverage was lower among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) adolescents and adults compared with non-Hispanic White (White) adolescents and adults. Among adults who were open to receiving booster vaccination, 58.9% reported not having received a provider recommendation for booster vaccination, 16.9% had safety concerns, and 4.4% reported difficulty getting a booster vaccine. Among adolescents with parents who were open to getting a booster vaccination for their child, 32.4% had not received a provider recommendation for any COVID-19 vaccination, and 11.8% had parents who reported safety concerns. Although bivalent booster vaccination coverage among adults differed by factors such as income, health insurance status, and social vulnerability index (SVI), these factors were not associated with differences in reluctance to seek booster vaccination. Health care provider recommendations for COVID-19 vaccination; dissemination of information by trusted messengers about the continued risk for COVID-19-related illness and the benefits and safety of bivalent booster vaccination; and reducing barriers to vaccination could improve COVID-19 bivalent booster coverage among adolescents and adults.

COVID-19 vaccine booster doses are safe and maintain protection after receipt of a primary vaccination series and reduce the risk for serious COVID-19-related outcomes, including emergency department visits, hospitalization, and death (1,2). CDC recommended an updated (bivalent) booster for adolescents aged 12-17 years and adults aged ≥18 years on September 1, 2022 (3). The bivalent booster is formulated to protect against the Omicron BA.4 and BA.5 subvariants of SARS-CoV-2 as well as the original (ancestral) strain (3). Based on data collected during October 30-December 31, 2022, from the National Immunization Survey-Child COVID Module (NIS-CCM) (4), among all adolescents aged 12-17 years who completed a primary series, 18.5% had received a bivalent booster dose, 52.0% had not yet received a bivalent booster but had parents open to booster vaccination for their child, 15.1% had not received a bivalent booster and had parents who were unsure about getting a booster vaccination for their child, and 14.4% had parents who were reluctant to seek booster vaccination for their child. Based on data collected during October 30-December 31, 2022, from the National Immunization Survey-Adult COVID Module (NIS-ACM) (4), 27.1% of adults who had completed a COVID-19 primary series had received a bivalent booster, 39.4% had not yet received a bivalent booster but were open to receiving booster vaccination, 12.4% had not yet received a bivalent booster and were unsure about getting a booster vaccination, and 21.1% were reluctant to receive a booster. Adolescents and adults in rural areas had a much lower primary series completion rate and up-to-date vaccination coverage. Bivalent booster coverage was lower among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) adolescents and adults compared with non-Hispanic White (White) adolescents and adults. Among adults who were open to receiving booster vaccination, 58.9% reported not having received a provider recommendation for booster vaccination, 16.9% had safety concerns, and 4.4% reported difficulty getting a booster vaccine. Among adolescents with parents who were open to getting a booster vaccination for their child, 32.4% had not received a provider recommendation for any COVID-19 vaccination, and 11.8% had parents who reported safety concerns. Although bivalent booster vaccination coverage among adults differed by factors such as income, health insurance status, and social vulnerability index (SVI), these factors were not associated with differences in reluctance to seek booster vaccination. Health care provider recommendations for COVID-19 vaccination; dissemination of information by trusted messengers about the continued risk for COVID-19-related illness and the benefits and safety of bivalent booster vaccination; and reducing barriers to vaccination could improve COVID-19 bivalent booster coverage among adolescents and adults.
NIS-CCM and NIS-ACM data were collected by telephone interview in English, Spanish, or other languages using a random-digit-dialed sample of cellular telephone numbers. Data collected during October 30-December 31, 2022,* were analyzed to assess demographic, behavioral, and social factors associated with COVID-19 primary series vaccination, †, §, ¶ bivalent booster receipt,** , † †, § § up-to-date COVID-19 vaccination status, ¶ ¶ and, among adults or their children who had * Approximates coverage as of November 30, 2022. † COVID-19 vaccination status was based on responses to the questions, "Have you received at least one dose of a COVID-19 vaccine?," "Which brand of COVID-19 vaccine did you receive for your first dose?," "How many doses of a COVID-19 vaccine have you received?," and "During what month and year did you receive your most recent COVID-19 vaccine?" § For adolescents aged 12-17 years, primary series completion was defined as completion of a 2-dose primary COVID-19 vaccine series. ¶ For adults, primary series completion was defined as receipt of a 2-dose primary mRNA or Novavax COVID-19 vaccine series for adults who are not immunocompromised or receipt of a 3-dose mRNA or Novavax COVID-19 vaccine series for adults who reported being immunocompromised. For respondents whose initial vaccine was Janssen (Johnson & Johnson) vaccine, primary series completion was defined as receipt of a single dose primary vaccine for adults who are not immunocompromised or receipt of 2-dose series for adults who reported being immunocompromised. ** For adolescents aged 12-17 years, bivalent booster dose was defined as, since September 1, 2022, the receipt of at least a third dose of COVID-19 vaccine after completion of a 2-dose primary series. † † For adults, bivalent booster dose was defined as receipt of at least a third dose of COVID-19 vaccine since September 1, 2022, after completion of 2-dose primary mRNA or Novavax vaccine series for adults who are not immunocompromised or at least a fourth dose of the vaccine after completion of a 3-dose mRNA or Novavax vaccine series for adults who reported being immunocompromised. § § For adults whose initial vaccine was a Janssen vaccine, bivalent booster dose was defined as the receipt of at least a second dose of COVID Primary series completion, up-to-date COVID-19 vaccination status, bivalent booster vaccination status, and intention to receive (or have one's child receive) a booster were stratified by race and ethnicity,*** metropolitan statistical area (MSA), † † † SVI, § § § other demographic characteristics, and behavioral and social drivers of vaccination (6). Persons considered open to booster vaccination included those who reported they definitely or probably would get booster vaccination for themselves or their child. Persons considered reluctant to receive booster vaccination included those who reported they probably or definitely would not get a booster for themselves or their child. Data were analyzed using SAS (version 9.4; SAS Institute) and SUDAAN (version 11.0.1; Research Triangle Institute). All percentages were weighted to represent the noninstitutionalized U.S. adolescent or adult population. ¶ ¶ ¶ T-tests were used to determine differences between groups with p<0.05 considered statistically significant. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.**** From interviews conducted during November-December 2022, 58.3% of all adolescents aged 12-17 years had *** Those who reported Hispanic ethnicity were classified as Hispanic and could be of any race. For adults, "non-Hispanic other/multiple races" included non-Hispanic adults who reported "other" race or more than one race. For adolescents, "non-Hispanic other/multiple races" included non-Hispanic American Indian or Alaska Native, non-Hispanic Native Hawaiian or other Pacific Islander, and non-Hispanic other or multiple races. † † † Urbanicity status was derived based on the centroid of the zip code of residence, categorized as MSA principal city, MSA nonprincipal city, or non-MSA. § § § Categorization into an SVI level was based on respondent-reported zip code of residence. https://www.atsdr.cdc.gov/placeandhealth/svi/index.html ¶ ¶ ¶ Survey weights were also calibrated by age and sex to state-level vaccine administration data reported to CDC by jurisdictions as of the middle of the monthly data collection period. https://covid.cdc.gov/covid-datatracker/ (Accessed November 29, 2022). **** 45 C.F.R. part 46.102(l) ( (Table 2). Among adults who had completed a primary COVID-19 vaccination series, 27.1% had received a bivalent booster, 39.4% had not yet received the bivalent booster but reported being open to booster vaccination (23.1% definitely would and 16.3% probably would), 12.4% were unsure about getting a booster, and 21.1% were reluctant to get a booster. Up-to-date COVID-19 vaccination status among all adults, and bivalent booster coverage among those who had completed a primary series increased from November (21.0% and 24.4%, respectively) to December (25.4% and 29.7%, respectively). Primary COVID-19 vaccination series completion was similar among White, Black, and Hispanic adults and higher among Asian adults than among those of all other races and ethnicities. Bivalent booster dose coverage was lower among Black (21.2%), Hispanic (15.0%), and Asian (25.1%) adults compared with White adults (32.1%). Bivalent booster coverage was higher among adults who had received a provider recommendation for booster vaccination (34.9%) than among those without a provider recommendation (22.2%). Bivalent booster dose coverage among adults who lived below the poverty level, were uninsured, and who lived in a moderate or high SVI county was lower than coverage among their less economically disadvantaged and lower SVI counterparts, although reluctance to seek bivalent booster vaccination generally did not differ by poverty, insurance, or SVI status. Adults in rural (non-MSA) areas had lower COVID-19 vaccine primary series completion rate and up-to-date coverage than those in MSA principal city areas.
Among all adults who had completed a COVID-19 primary series, 5.2% reported difficulty getting a booster vaccine, with a higher percentage of those open to booster vaccination (4.4%) and unsure about booster vaccination (6.6%) reporting difficulty than did those who were already vaccinated (3.6%) ( Table 3). The most common barrier reported was difficulty getting an appointment (5.5% of adults). Overall, among all adults who had completed a COVID-19 vaccine primary series, Black, Hispanic, and non-Hispanic American Indian or Alaska Native adults were more likely to report difficulty getting a booster vaccine, and Black and Hispanic adults were less likely to report confidence about COVID-19 vaccination safety and receipt of provider recommendation for booster vaccination compared with White adults (Supplementary Table 1, https://stacks.cdc.gov/view/cdc/124394). Among adults who were open to or unsure about booster vaccination, 41.1% and 28.7%, respectively, received a provider recommendation for booster vaccination (58.9% and 71.3%, respectively, did not receive a provider recommendation), and 83.1% and 54.5% of adults, respectively, were confident about COVID-19 vaccination safety (16.9% and 45.5%, respectively, had safety concerns) ( Table 3). Among adolescents with parents who were open to or unsure about booster vaccination for their children, 67.6% and 54.8% of these parents, respectively, received a provider recommendation for any COVID-19 vaccine for their child (32.4% and 45.2% did not receive a provider recommendation), and 88.2% and 54.4% of these adolescents, respectively, had parents who were confident about COVID-19 vaccination safety for their child (11.8% and 45.6%, respectively, had parents with safety concerns). Adults and parents of adolescents overwhelmingly reported that a COVID-19 vaccine is important (54%-98% across bivalent booster vaccination and booster vaccination intent       categories). Over one half of adults and parents of adolescents reported that vaccination is important, even among those who were reluctance to seek a booster vaccine.

Discussion
From interviews conducted during November-December 2022, approximately 20% of adolescents aged 12-17 years and approximately 30% of adults who had completed a primary COVID-19 vaccination series had received a bivalent booster dose since it was recommended on September 1, 2022. However, a large percentage of adults and parents of adolescents reported intent to receive booster vaccination for themselves or their children, indicating that booster vaccination coverage could substantially increase with appropriate interventions tailored to these reachable populations.
Reduction in disparities in completion of primary COVID-19 vaccination by race and ethnicity likely contributed to a reduction in the disparities in COVID-19 age-adjusted mortality rates that were observed early in the pandemic (7). However, bivalent booster coverage was lower among Black and Hispanic adolescents and adults compared with White adolescents and adults. Tailored and community-led interventions that helped reduce racial and ethnic inequities in primary COVID-19 vaccination could help address reported racial and ethnic differences in barriers to and attitudes toward booster vaccination. These strategies include creating and training a network of local community-trusted messengers to address  Alaska, Idaho, Oregon, and Washington. ¶ ¶ Essential worker groups were categorized as essential healthcare personnel (including health care, social service, and death care workers), school and child care (including preschool or child care, K-12 school, and other schools and instructional settings), other frontline (including first response [e.g., police or fire protection], correctional facility, food and beverage store, agriculture, forestry, fishing, or hunting, food manufacturing facility, nonfood manufacturing facility, public transit, and United States Postal Service), other essential (including other essential that are not listed above), and "not a frontline or essential worker" (including those who were not employed). *** Disability was defined as an affirmative response to the following survey question: "Do you have serious difficulty seeing, hearing, walking, remembering, making decisions, or communicating?" misinformation and promote accurate, culturally appropriate vaccine messaging; providing vaccination in additional settings such as churches, barbershops, mass vaccination sites, or community sites; and working with culturally competent health care providers to provide a recommendation for bivalent booster vaccination. † † † †, § § § § Although bivalent booster vaccination coverage among adults differed by factors such as income, health insurance status, and SVI, these factors were not associated with differences in reluctance to seek booster vaccination. This finding suggests † † † † COVID-19 vaccine equity for racial and ethnic minority groups.    * For adolescents, booster vaccination intent represents reported parental intent to get a booster vaccine for their child. † Weighted percentage. § Respondents who had received a booster dose were asked, "How difficult was it for you to get a COVID-19 booster vaccine?" Respondents who had not received a booster dose were asked, "How difficult would it be for you to get a COVID-19 vaccine booster?" ¶ p<0.05 by T-test for comparisons with those who received bivalent booster vaccination as the reference level. ** p<0.05 by T-test for comparisons with those who have not received bivalent booster but will definitely or probably get bivalent booster as the reference level. † † Questions were asked about COVID-19 vaccination generally and not specifically about COVID-19 booster dose vaccination.

. Barriers to receiving COVID-19 booster vaccination among adults and attitudinal and social factors regarding COVID-19 vaccination among adults and adolescents, by bivalent booster vaccination and booster vaccination intent* among those who completed a COVID-19 vaccine primary series -National Immunization Survey-Adult COVID Module and National Immunization Survey-Child COVID
to vaccination, more than one half of adults and one in three parents of adolescents did not receive a provider recommendation. Those who were unsure about booster vaccination for themselves or their children, and thus also potentially reachable to be vaccinated, were even less likely to have received a provider recommendation. Safety concerns about vaccination were also prevalent among those open to or unsure about booster vaccination. Provider recommendations to all patients that include culturally appropriate communication about the benefits and safety of booster vaccination and dissemination of information about the safety of vaccine by other trusted messengers could improve COVID-19 vaccination coverage (8).
The findings in this report are subject to at least four limitations. First, response rates of the NIS-CCM and NIS-ACM were low (18% and 23%, respectively). Although survey weights were calibrated to COVID-19 vaccine administration data to mitigate possible bias from incomplete sampling frame, nonresponse, and misclassification of vaccination status, bias in estimates might remain after weighting. Second, COVID-19 vaccination was self-reported and might be subject to recall or social desirability bias. Third, respondents were not specifically asked about bivalent boosters, and all boosters received after September 1, 2022, were assumed to be bivalent boosters, which might have overestimated bivalent booster coverage if some persons had received a monovalent booster after September 1, 2022. Finally, the survey sampled noninstitutionalized U.S. adults via mobile telephone; therefore, adults who were incarcerated or nursing home residents might not be represented in the sample.